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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701084
Report Date: 12/16/2022
Date Signed: 12/16/2022 10:44:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2022 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20221214102015
FACILITY NAME:R & E SENIOR CARE, INC.FACILITY NUMBER:
342701084
ADMINISTRATOR:EMILY PASCUAFACILITY TYPE:
740
ADDRESS:5231 OLIVEHURST WAYTELEPHONE:
(916) 895-4357
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emily PascuaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Residents are not being supervised adequately.
Uncleared adult in home aiding resident in home
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/16/22 at 9:00am to investigate the above-mentioned allegations. LPA met with Emily Pascua, Administrator and stated the purpose of the visit. LPA conducted a review of the LIS and Guardian to research if the named person that was left alone with the residents on 12/13/22 were fingerprinted and associated to the facility. Complainant witnessed the unfingerprinted, not associated person working in the facility on 12/13/22. LPA interviewed Emily Pascua, Administrator during this visit. Based on confirmation of the Administrator that this occurred, the above allegation(s) is found to be SUBSTANTIATED. Civil Penalty assessed in the amount of $500.00. (See LIC421IM)
A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided.
Substantiated
Estimated Days of Completion: 30
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20221214102015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: R & E SENIOR CARE, INC.
FACILITY NUMBER: 342701084
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/17/2022
Section Cited
CCR
87355(e)(1)
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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department
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Administrator shall submit a copy of live scan, proof of guardian association and/or a plan on how the facility will secure supervision of the residents which shall be faxed by POC due date.
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This requirement is not met as evidenced by: LIS revealed person not associated and Guardian revealed person not finger print cleared
Based on Confirmation from Administrator the person left with the residents was not finger printed nor associated to the facility.
This poses an immediate health and safety risk to residents in care.
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You are hereby notified that an immediate civil penalty of $500.00 is assessed for a violation that resulted in residents being left alone with a person that was not finger print cleared nor associated to the facility.
(See LIC421IM)
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
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